So what are safe staffing levels in care homes?

CQC inspectors often criticise staffing levels during inspections which can be concerning for providers. This Ridout Report considers what the regulations say about staffing levels, CQC’s new inspection regime and practical steps providers can take to determine staffing.

The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, called the fundamental standards, came into force this month. Regulation 18 in relation to staffing states that: ‘Sufficient numbers of suitably qualified, competent, skilled and experienced persons must be deployed in order to meet the requirements of this Part.’ In summary, this means that employees must—

Receive appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out their duties.

Be enabled where appropriate to obtain further qualifications appropriate to the work they perform.

Be enabled to provide evidence to the regulator that they continue to meet the professional standards which are a condition of their ability to practise or a requirement of their role.

The intention of this regulation is to make sure that providers deploy enough qualified, competent and experienced staff to enable them to meet all the other regulatory requirements.

The legislation does not indicate what safe staffing levels are and there is no official tool for calculating appropriate staffing levels. However, there are some tools which are well known and commonly used within the sector. An official tool is unlikely to work because many services care for a range of service users with varying needs and a one-size-fits-all approach is inappropriate. Staffing levels therefore need to be determined based on the needs of service users, occupancy levels, taking into account the nature of the premises and staff training requirements.

CQC’s guidance ‘Guidance for providers on meeting the regulations’ (February 2015) states that to meet the requirements of regulation 18, ‘providers should have a systematic approach to determine the number of staff and range of skills required in order to meet the needs of people using the service.’ Providers should also consider, ‘the different levels of skills and competence required to meet those needs, the registered professional and support workers needed, supervision needs and leadership requirements.’

CQC’s new regime of inspection

Under CQC’s new regime of inspection which came into force in October 2014, inspectors focus on asking five key questions which are judged on a standard set of key lines of enquiry. During inspections of residential adult social care services, one of CQC’s mandatory key lines of enquiry for the question is the service safe, relates to staffing and asking the question: ‘How does the service make sure that there are sufficient numbers of suitable staff to keep people safe and meet their needs?’

For the service to be rated as ‘good’ there must always be, ‘enough competent staff on duty who have the right mix of skills to makesure that practice is safe and they can respond to unforeseen events. The service regularly reviews staffing levels and adapts them to people’s changing needs.’

CQC will consider if staffing levels are regularly assessed to ensure they are sufficient to meet people’s individual needs. CQC will look to see if providers have taken into account the layout of the building. They will also look at the arrangements in place for making sure that staffing levels have the right mix of skills, competencies, experience and knowledge, to meet people’s needs.

Evidence CQC may rely on to assess staffing levels is as follows:

Details of enquiries, including compliments, concerns and complaints, and if available, share your experience forms.

Gathering feedback from external professionals.

Asking services users how staffing levels affect their day-to-day lives i.e. their safety and care management in both a positive or negative way. This may also include talking to their relatives.

Observing if people’s needs are met and they are safe, looking to see if call bells or other requests for support are answered promptly, observing staff handovers to see how staff are deployed and how shifts are covered to meet people’s needs.

Speaking to staff to hear their views on the staffing at the service, including how shifts are covered, particularly at weekends and night time.

How staffing levels are maintained – whether they are increased at busy times and how staff are used across the service to meet the different needs of the people they care for and support. CQC will also consider how agencies are used and what recruitment processes have been followed.

Reviewing records: if CQC inspectors have concerns that there may be a breach of regulations, they may wish to look at people’s risk assessments or individual care files, staffing level assessment systems, staff handover records, staff rotas over time, agency records, and minutes of meetings. Internal quality assurance feedback, quality assurance records on patterns/timings of accidents and incidents and, where available any call bell timing records. Staff files for recruitment, staff disciplinary procedures and other policies may also be reviewed.

Conclusion

The days of staffing matrices linked to service user numbers have long gone. It is also not enough to rely simply on professional judgement, although this should always remain as a key element in judging the overall adequacy of staffing – it should never be a computer based exercise. What is key is having a systematic approach linking dependency to staffing levels. Some providers will use an established model while others will use more than one mechanism to determine appropriate staffing levels including measuring the number of residents requiring a single carer or two carers, direct observation and RCN guidelines, to name but a few.

Due regard should always be given to the CQC guidelines. To ensure a provider is compliant with staffing requirements, providers should have regard to CQC’s Key Lines of Enquiry and the evidence that inspectors will take into account when determining whether a service is ‘good’. In particular, providers should consider the individual needs of service users in relation to the number of care hours being provided. The views of service users and staff are also important as well as staff deployment.

Although CQC cannot prosecute for breach of regulation 18, it can take other regulatory action by using its civil powers to impose conditions, suspend a registration or cancel a registration. It is therefore essential that providers have a systematic approach to justify staffing levels which is kept regularly under review by service managers and external advisors.